Member in the News Kelli Stidham Hall

Purpose: As part of a broader effort to study the social environment of adolescent sexual and reproductive health (SRH) in Ghana, we qualitatively explored the determinants and consequences of sexual activity, contraceptive use, pregnancy, early childbearing, abortion, and family planning (FP) service use among young Ghanaian women, including the role of social stigma in shaping FP experiences and outcomes.

Methods: In our qualitative study, which was the first phase of a larger mixed methods project, we conducted in-depth, individual, semi-structured interviews with 63 adolescent and young adult women ages 15-24 in Accra and Kumasi, Ghana. Women were recruited from 5 secondary schools and 5 health facilities. Purposive sampling was used to ensure diversity in reproductive, relationship, and socioeconomic backgrounds. Interviews were conducted in local languages or English, recorded, and transcribed verbatim. Applying principles of grounded theory, we conducted a thematic analysis to identify key codes and themes using Dedoose software.

Results: Stigma and discrimination emerged as one of five major themes. Young women described personal feelings and lay attitudes that adolescent sexual activity and its consequences (particularly non-marital sex, contraceptive use, pregnancy, and childbearing, and abortion generally) are perceived to be acts of disobedience, “disgrace,” “disrespect,” “shame,” and contribute to community “gossip” and “bad girl” labeling. Enacted stigma was described as experiences of discrimination, marginalization, and psychological and physical mistreatment of sexually active, pregnant, and parenting adolescents by family members, peers, intimate partners, teachers, religious leaders, and health care workers. Secretkeeping and non-disclosure, which were strategies used to avoid or reduce stigma, impacted sexuallyactive adolescents’ willingness to seek FP services and use modern contraception. Other salient themes (described in expanded results) included: 1) multiple levels of influence on adolescent SRH; 2) health and social consequences of adolescent SRH; 3) abortion attitudes and access; and 4) lack of knowledge and negative perceptions and experiences with FP methods and services.

Conclusions: Ghanaian adolescents’ experiences with sexual activity, contraception, pregnancy, early childbearing, abortion, and FP service use are shaped by diverse, multi-level, and often negative influences within their social environments and have significant implications for their broader health and wellbeing. Notably, stigma appears to preclude effective FP and contribute to unintended pregnancy and its sequelae. Findings from this qualitative work informed development of a new stigma scale, which we used in our community-based survey study of 1,069 Ghanaian young women to quantitatively measure the social context of adolescent SRH and its impact on FP, health, and social outcomes.